Caring for seniors where they live

For most elders who become gravely ill in the middle of the night, there is only one option: Call 911 and let an ambulance take you to the nearest emergency room.

But Phyllis Hall, a resident of the Sunnyside Manor assisted-living facility in Sarasota, had a less drastic and more comfortable alternative. When she experienced trouble breathing, the facility’s nursing staff sent for Cindy Drew.

“One night when I was very sick here, she came, and I was so happy to have her then,” Hall remembers.

Since that alarming episode, after six months in Drew’s care, Hall’s severe lung problems appear to have stabilized — so much so that the two spent most of a recent check-up discussing ways to relieve Hall’s lower back pain.

Drew, a traveling nurse practitioner who specializes in elder patient care, is one of a rare breed: Of some 189,000 nurse practitioners in the United States, only about 3.2 percent have a gerontological focus. But with 78,000 baby boomers on the precipice of later life — along with a chronic shortage of geriatricians and primary care physicians — the field is poised to explode.

A baby boomer who decided on a nursing career when she was 17, Drew has been a pioneering nurse practitioner since 1988. About 14 years ago she began working with long-term care facilities, and has helped many others learn her specialty. She knows of six local nurse practitioners who have begun focusing on elders in the last year alone.

Nurse practitioners have advanced clinical training and graduate-level educations. Like physicians, they can diagnose medical problems and prescribe drugs. But they can often be easier to contact.

Drew, 58, is self-employed but affiliated with Sarasota Memorial Hospital and has relationships with local physicians. She goes every day to where her patients live — in nursing homes, memory care units, assisted-living facilities and private homes.

“In most places they have to pay for transportation if they want to see a doctor,” she said. “Plus, there’s a risk of falling when they go out, and it’s stressful for them. Dementia patients can get very distraught when they go out; if I can see them, most times they don’t have to go to the hospital.”

And there are other advantages to this twist on the old-fashioned doctor’s house call.

For patients like 90-year-old Barbara Scott — who moved to Sunnyside from her native Massachusetts to be near daughter Wendy Hopkins — being examined by Drew in her cozy living room can feel more like a social visit than an office appointment.

Between conversations about Scott’s grandchildren, her dog and her old friends back home, Drew listens to her heart and lungs and interjects gentle questions: “How’s your breathing? How did you sleep last night?”

Drew spends more time with each elder than most doctors can — as long as it takes, and on this day, a little more than 20 minutes apiece. When patients can’t remember how long they have felt a symptom, or when they noticed a crucial change, she circles back to ask the same question in a different way, each time digging up a few more clues.

If something is important — a test will be ordered, or a drug regime altered — she repeats the information at least three times. It’s a trick from her years as a nursing teacher.

Drew says that over time, she learned from her physician mentors that older patients respond best to a methodical but upbeat manner.

“I used to say things out loud, like you would with any patient, things like, ‘Oh, I see you have a heart murmur,’ ” she says. “Then a cardiologist I worked with told me that with the elderly population, you don’t want to say anything unnecessary that will make them worry. You need to be reassuring them.”

Drew came by her knowledge gradually over 30 years, and is happy to be part of a field that is expanding swiftly.

“I was never able to work with other nurse practitioners because I was one of the first ones,” she says. “But now I feel I’m passing all this on to other nurse practitioners.”

Winding up her visit with Scott, Drew asks several times if there are any medical issues they haven’t touched on yet.

“I know that the major thing is your eye and your knee and your shortness of breath,” she tells her. “Are there any other concerns?”

“No,” Scott answers her, laughing. “I think that’s enough.”

But Hopkins, her daughter, brings up some fresh questions, and Drew takes time to address them. She finishes by offering to schedule regular doses of Scott’s pain medication, because Hopkins worries that her mother has been waiting too long to take it on her own — past the point when it could be most effective.

Then Drew promises to follow up almost immediately, with another visit in two days.

Hopkins says she appreciates the extra layer of medical care that Drew provides, between a physician’s clinic and the caregivers at Sunnyside.

“There have been a couple of times when Mom has called me very short of breath,” Hopkins says, “and I’ll call Cindy and say, ‘I need for you to come over and check her out.’ The nurses are very, very good here, but there’s a level of confidence I have in Cindy. She’s the next-best thing to a doctor.”

In Florida, nurse practitioners like Drew are not completely independent. They have to have a “protocol” relationship with a licensed medical doctor, and Drew maintains several. In fact, she says, these physicians have helped build her practice.

“It’s usually word of mouth,” she says. “I’ve been asked by physicians sometimes to check on their patients who can’t get out. These are people who would probably go to the ER by ambulance if someone didn’t come to see them — and it can be something as simple as constipation.”

But, she adds, there are frustrations that come with being a nurse practitioner in Florida. When she worked with a cardiology practice in Tennessee — before returning to Sarasota to be with her own aging parents — she could prescribe any medications her patients needed. But Florida is one of two states where only doctors are licensed to prescribe drugs controlled by the Drug Enforcement Administration.

“It’s a lot more than oxycontin,” she says, referring to the often-abused narcotic. “This includes cough medicines and anti-seizure drugs.

“Every day,” she adds, “I see a patient that needs something that requires DEA authority, and physicians are in their office seeing patients and I’m having to call them and tell them what’s going on and ask them to prescribe. And my patients have to wait while I do all this.”

The Legislature could address the issue this spring. The Florida House’s Select Committee on Health Care Workforce Innovation has approved a sweeping bill that would give nurse practioners considerably more authority, though that measure is opposed by the Florida Medical Association and the Senate president, Don Gaetz, R-Niceville. A more limited Senate bill would allow nurse practitioners to prescribe controlled substances.

Despite current obstacles, nurse practitioners can make everyday life a lot sweeter for their patients — sometimes with a low-tech, common-sense solution for a small problem.

To manage her lung disorder, Phyllis Hall must take medications six times a day. Drew worked with the Sunnyside staff so that Hall could do this more conveniently, using a bank of three weekly pill containers, clearly labeled with days and times.

Drew asks her how the new routine is going.

“I like it,” Hall tells her, smiling. “I have to take things so many times a day, and the nurses would have to be running in and out. Now, it’s working out fine.”

LEGISLATIVE UPDATE
Two bills have been introduced in Tallahassee that would give greater scope to nurse practitioners in Florida. A House bill (HB 7071) would allow them to operate independently of physicians, and also to prescribe drugs that are controlled substances. A less ambitious Senate bill (SB 1352) would keep the physician contract requirement, but let nurse practitioners prescribe controlled substances without a doctor’s approval.

The Florida Association of Nurse Practitioners is backing the legislation, arguing that Florida has a shortage of primary care physicians, and fewer than half of those physicians accept Medicaid patients. The group states: “Removing restrictive nurse practitioner licensure laws has been demonstrated in other states to increase primary care access and reduce costs. Less restrictive licensing also has shown an added benefit of attracting more nurse practitioners into a state, thus improving economic activity. Almost half the states have stopped the practice of restricting NP licensure.”

But the Florida Medical Association opposes both bills, saying nurses’ efforts to practice independently and prescribe narcotics “is dangerous for patients. There is no evidence that such broad-based expansion will reduce costs to the healthcare system. While the FMA values physician extenders and the important role they play in the healthcare team, allowing them to practice independently and prescribe narcotics is unnecessary and unsafe.”

Barbara Peters Smith

Barbara Peters Smith covers aging issues for the Sarasota Herald Tribune. She can be reached by email or call (941) 361-4936.

Last modified: March 13, 2014
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